1205009016 NPI number — MRS. ALISA BROOKE GRISMER PHARMD

Table of content: MRS. ALISA BROOKE GRISMER PHARMD (NPI 1205009016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205009016 NPI number — MRS. ALISA BROOKE GRISMER PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRISMER
Provider First Name:
ALISA
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205009016
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15800 95TH AVE N
Provider Second Line Business Mailing Address:
PARK NICOLLET
Provider Business Mailing Address City Name:
MAPLE GROVE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55369-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-993-1414
Provider Business Mailing Address Fax Number:
952-993-1389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15800 95TH AVE N
Provider Second Line Business Practice Location Address:
PARK NICOLLET
Provider Business Practice Location Address City Name:
MAPLE GROVE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55369-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-993-1414
Provider Business Practice Location Address Fax Number:
952-993-1389
Provider Enumeration Date:
04/12/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  117219 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)